Widespread Rash Research Articles

Papulonecrotic tuberculide: a forgotten cutaneous manifestation of tuberculosis

A 30-year-old Chinese man presented with a 2-month history of enlarging neck masses and a widespread rash. He had first noticed the swellings 10 years ago when a diagnosis of tuberculosis was made. The lymphadenopathy improved after anti-tuberculous therapy but never completely regressed. Seven years later, a skin eruption developed over his limbs and trunk. He described recurring crops of asymptomatic reddish papules which discharged a yellowish fluid and subsequently healed with scarring and hyperpigmentation. There was no pruritus or tenderness and no pulmonary symptoms. Clinical examination revealed a non-tender, 10 cm, firm and ovoid mass with overlying erythema in the right anterior triangle of his neck (Figure 1) with several smaller lumps on the other side. There was a widespread eruption on his trunk and limbs, sparing the face, palms, sole and scalp (Figure 2). Recent lesions consisted of 1cm erythematous papules with a scaly collarette (Figure 3). Older lesions had left atrophic scarring and hyperpigmentation. A clinical diagnosis of papulonecrotic tuberculide was made. An X-ray of the chest was normal. Serum immunoglobulins (IgG, A and M) were moderately elevated. Erythrocyte sedimentation rate and C-reactive protein level were normal. Syphilis serology was negative. A Heaf test was strongly positive (Figure 4). Fine needle aspirations of the neck mass were negative for microscopic identification of acid-fast bacilli and for malignancy. On the other hand, a lymph node biopsy on the left side revealed fragments of connective tissue showing granulomatous inflammation and non-caseating necrosis. Occasional acid-fast bacilli were seen with a Ziehl-Neelsen stain. Skin biopsies were taken of recent, established and old lesions. The histological features of the established lesion were diagnostic, showing a florid, acute on chronic, perivascular and periappendiceal inflammmatory infiltrate involving both the superficial and deep dermis. There was also evidence of lobular panniculitis with fibrinoid necrosis of medium-sized arterial vessels, venulitis and extensive endothelial cell swelling. Histological features of the other two skin specimens were non-specific. No organisms were identified with special stains. Anti-tuberculous therapy with rifampicin, isoniazid and pyrazinamide was started and 2 weeks after treatment, the patient reported a complete cessation in the development of new skin lesions. His skin remains in remission after 6 weeks of treatment.

Brother and sister with different vasculitides

A brother and sister came to our observation at the ages of 3·6 years and 16 months. 20 days before admission, both had pharyngitis treated with amoxicillin for 10 days. 10 days before admission, niflumic acid was given to the girl for rhinitis. 2 days later, a purpuric rash appeared on her legs and she had abdominal pain. Henoch-SchÖnlein purpura (HSP) was diagnosed. Three days later, her brother had a cough and rhinitis and was given ketoprofen. The next day he developed a widespread rash (figure) consistent with the diagnosis of acute haemorrhagic oedema of childhood (AHE).

Irradiation protection from hypersensitivity

A 71-year-old man with metastatic carcinoma of the prostate was admitted for investigation of severe lower back pain. Spinal-cord compression at the level of the tenth thoracic vertebra (T10) was suspected clinically and multiple areas of vertebral bone metastases were seen on technetium bone scan. He was treated with bed rest, high-dose dexamethasone (4 mg four times a day) and a course of radiotherapy (5 MeV, 2000 cGy in 5 fractions over one week to his thoracic spine as a single posterior field, 8 15 cm), followed by radiotherapy to the lumbar spine (5 MeV, 2000 cGy in 5 fractions over 5 days as a single posterior field, 8 15 cm) as a site of known bony disease. On completion of radiotherapy, the dose of steroids was reduced and stopped, he was mobilised and started on cyproterone acetate (100 mg three times a day). A widespread maculopopular rash developed 2 weeks after completing radiotherapy. The rash covered most of his body except the areas (on both the front and back of his trunk) which had received a dose of radiotherapy (figure). He was treated with piriton and calamine lotion for the mild itch and discomfort associated with the rash. He had no known drug allergies, his medication before appearance of the rash included cyproterone acetate, goserelin, dexamethasone, subcutaneous heparin, codanthrusate, paracetamol, cimetidine, lactulose, and fybogel. He had recently received a blood transfusion. The rash was thought to be a result of cutaneous hypersensitivity although no cause was found, and it slowly faded. Our hypothesis is that skin within the radiation treatment field received a dose of radiotherapy (2000 cGy posteriorly and 600 cGy anteriorly) sufficient to result in local suppression of an otherwise generalised rash. Although the treatment was given as a single posterior field to both sites, a significant dose (approximately 600 cGy) would exit through the anterior surface of the patient at this energy. There are several possible explanations for this observation. Photon irradiation may have resulted in an altered response to an allergen or internal factors, or a cell population was affected in either a functional way (receptor alterations, cytokine production, intercellular or extracellular signals) or by depopulation. We were unable to take skin biopsies in this case which may have helped to elucideate the mechanism of this observed phenomenon. It is known that Langerhans cells have a role in both contact and atopic dermatitis, and that they exhibit multiple cell-surface receptors (allowing antigen recognition) and secrete a variety of cytokines (providing a mechanism for the observed ‘dermatitis’). Whilst there is no data on the sensitivity of Langerhans cells to megavoltage photon irradiation (as used in this case). Grenz rays (which are much less penetrating) delivered to the skin of people with contact hypersensitivity to nickel resulted in almost total suppression of allergic contact dermatitis in treated skin. Biopsies of skin showed pronounced reduction in numbers of Langerhans cells in the irradiated area as demonstrated by the monoclonal antibody OKT6.

Pharmacokinetics of 18F-labeled trovafloxacin in normal and Escherichia coli-infected rats and rabbits studied with positron emission tomography

Clin Microb Infect 1997; 3: 63-72 On page 67, Figure 3 was published in black and white, which did not allow proper examination of drug concentrations. We reproduce the color version below: Michel Tod, Olivier Lortholary, Christophe Padoin and Gilles Chaine Clin Microb Infect 1997; 3: 143-4 In this Letter to the Editors, the first word in the title was published incorrectly as intravenous. We reproduce the correct title above. Illustrated continuing medical education - Case 2Clinical Microbiology and InfectionVol. 3Issue 3PreviewA 24-year-old homosexual man presented with a one week history of headaches, myalgia, and a rash. He had not been eating well and had vomited once after drinking heavily at the weekend. He had recently returned from a holiday to the Mediterranean. On examination he was febrile (37.8 °C), had enlarged cervical and inguinal lymph nodes, and a widespread maculopapular rash. He had a mild pharyngitis and generalised lower abdominal tenderness. His white cell count was 2.9 × 109/l and his blood film is shown above. Full-Text PDF Open ArchiveErrataClinical Microbiology and InfectionVol. 3Issue 3PreviewClin Microb Infect 1997; 3: 63-72 Full-Text PDF Open Archive

Successful Treatment of Multisystem Langerhans Cell Histiocytosis (Histiocytosis X) with Etoposide

Langerhans cell histiocytosis (LCH) in its disseminated form usually occurs in the very young, and has a fulminant, rapidly progressive, and fatal course despite different forms of therapy. We treated two patients, who had failed on vinblastine treatment, with i.v. etoposide (VP-16) at a dose of 150 mg/kg/day for 3 days. Patient I, 8 months of age, presented with failure to thrive and huge bilateral granulomatous lesions of the external auditory canal with erosion and extensive destruction of the petrous pyramids and mastoid area. Patient II, 20 months of age, presented with widespread purpuric skin rash, hepatosplenomegaly, and bone marrow involvement. Both patients sustained complete remission (CR) following three to six courses of VP-16 and continued to be in unmaintained CR for > 48 months from diagnosis. No major toxicity was noted. Etoposide (VP-16), an epipodophyllotoxin known for its usefulness in the treatment of malignancies of the monocyte/macrophage lineage, appears to be an effective treatment for the severe multisystem (disseminated) LCH of childhood and should be strongly considered as front-line therapy for this subgroup of patients with poor prognostic factors.

An Outbreak of Tinea Corporis Among Schoolgirls

The purpose of this report is to describe an outbreak of tinea corporis due to Microsporum canis with an atypically widespread rash among a group of preteen and teenage schoolgirls. M canis is found worldwide as a common dermatophytic infection of both glabrous and hairy skin. Nosocomial out-breaks, which have been described in the institutional setting among geriatric patients and their caretakers, were thought to be transmitted by direct contact, contaminated linens, and shared razors.1 However, in the general population, the chief source of contagion of this zoophilic infection is domestic animals, particularly kittens.2 CASE REPORTS Within a period of 12 days in November 1989, seven girls, aged 12 through 15 years, were seen with the presenting complaint of a rash.

Acute infectious erythemas in children: a clinico-microbiological study

One-hundred children with an acute illness comprising fever and widespread erythematous rash were prospectively studied to determine whether clinical presentations are helpful in defining the causative agent and to identify the most appropriate microbiological specimens. An infectious agent was identified in 65 children; 72% were viruses, 20% were bacteria, 5% were Mycoplasma pneumoniae and in 3% both viruses and bacteria were detected. The most common infectious agents were picornaviruses, an atypical presentation of measles and Group A beta-haemolytic Streptococcus. Different patterns of rash occurred with each of these infections. The clinical presentation of a child with an acute febrile illness and rash was unhelpful in defining the causative agent. Routine management should include a throat swab for bacterial investigation and in selected cases a blood sample for IgM viral titres.

Cutaneous reaction to diltiazem resulting in an exacerbation of angina

A 77-year-old woman developed a widespread erythematous rash after treatment with the calcium antagonist, diltiazem, which resulted in an exacerbation of the angina for which the drug was originally described. Drugs which may give widespread cutaneous side-effects should be used with caution in patients with compromised cardiac function.

Adverse reactions to piperacillin in adults with cystic fibrosis.

Nine adult patients with cystic fibrosis, nearly a quarter of the 38 patients with this disease who were treated with piperacillin (59 courses in all) during 1981-3 at the Brompton Hospital, developed a swinging pyrexia after a mean of 13.5 days' treatment with this antibiotic. The fever resolved shortly after the piperacillin treatment was stopped, as did the widespread rashes in the two patients who developed them. Three of four patients who had probable reactions to azlocillin may have been sensitised by piperacillin. As piperacillin does not appear to be any more effective than other antipseudomonal penicillins in cystic fibrosis, it is no longer used at the hospital for treating bronchopulmonary exacerbations in such patients.

A case report of systemic cryptococcosis with Lennert's lymphoma

We report here a case of systemic cryptococcosis with Lennert's lymphoma. The significance of the titer of the antigen and antibody of Cryptococcus neoformans was studied throughout the clinical course of the patient.The patient, a 42-year-old female, was admitted to Tsukuba University Hospital in November, 1980, because of fever and skin rash. She had widespread skin rash and lymphadenopathy, and hepato-splenomegaly. A diagnosis of Lennert's lymphoma was made from the patholopy of the biopsy specimen of her right cervical lymphnode. The clinical stage of the disease was IVB. The eight courses of combination chemotherapy brought about a little effect on the disease. However, she subsequently had a sudden onset of high fever, with a severe headache and nausea and further, different, skin rash on the face. C. neoformans were detected from venous blood, cerebrospinal fluid (CSF) and skin secretion. A diagnosis of systemic cryptococcosis was made. She was simultaneously given amphotericin B intravenously and intrathecally for 3 weeks. Thereafter she was further treated with intrathecal amphotericin B for 6 weeks and oral flucytosine for 7 months. Her cryptococcal meningitis immediately improved following the start of the initial therapy. Two months later all the cultures of C. neoformans from CSF, blood and skin secretion was negative. She completely recovered from cryptococcosis and lymphoma and was still well on March 30, 1985.The antigen titer of C. neoformans in her serum and CSF was serially measured by latex particle agglutination method and the antibody titer by slide agglutination test from December, 1980 to July, 1983. Antigen titer in the serum was negative until 2 weeks prior to the diagnosis of cryptococcosis. The antigen titer was very high when meningitis occured but gradually fell as meningitis recovered clinically. The antibody was never detected in serum and CSF.These results suggest the following conclusions: 1. C. neoformans antigen titer in the serum indicated the state of systemic cryptococcosis. The titer is, therefore, valuable for the diagnosis and prognosis of the disease.2. The inability to detect C. neoformans antibody in both her serum and CSF indicates the antibody titer may not be of clinical value in immunodeficient patients.

Recent widespread scaly rashes.

Recent widespread scaly rashes.

Morbilliform Skin Eruption Owing to Diethylstilbestrol

We describe an unusual case of morbilliform skin eruption caused by diethylstilbestrol in a patient with stage D prostatic cancer. A widespread erythematous maculopapular rash and urticaria appeared with repeated challenges of diethylstilbestrol and resolved with drug withdrawal. In addition, the literature on various types of dermatitis medicamentosa in male patients with prostatic cancer treated with diethylstilbestrol is reviewed.

Pityriasis lichenoides chronica presenting as hypopigmentation

Seven black or dark skinned patients with pityriasis lichenoides chronica (PLC) are described, who presented with widespread hypopigmentation. The evidence on which a diagnosis of PLC was made is presented and the differential diagnosis discussed. The hypopigmentation was noted in some patients to be especially marked on the proximal parts of the limbs and axillary folds. A diagnosis of PLC should be considered in all dark skinned patients with a widespread hypopigmented rash.

A Controlled Comparative Trial of Butacote and Fenclofenac in the Treatment of Ankylosing Spondylitis

A double-blind crossover trial of fenclofenac was undertaken to compare the short-term effects of phenylbutazone (Butacote) therapy with fenclofenac therapy (1200 mg daily) in 23 patients suffering from ankylosing spondylitis. The patients were randomly allocated to each of the test drugs for a period of two weeks, following wash-out periods of paracetamol for four days. The results favoured Butacote therapy in a dosage of 300 mg daily in the expressed preferences of both the patients and the physicians conducting the trial. Butacote was also better tolerated, as no severe side-effects occurred during treatment, whereas five patients developed a widespread rash during the period of fenclofenac therapy. No significant differences were seen between the two drugs in terms of clinical measurements of pain, morning stiffness, spinal movements, chest expansion, and abduction of the hips. Butacote was shown to cause some significant depletion of haemoglobin level, probably due to water retention, and Butacote also reduced the serum urate level to a significant degree.

Systemic lupus erythematosus in a 1-year-old child.

An 11-month-old girl had systemic lupus erythematosus with a widespread skin rash. She manifested five of the criteria necessary for the diagnosis: oral ulcerations, alopecia, positive lupus erythematosus preparations, convulsions, and thrombocytopenia with leukopenia. Direct immunofluorescence showed deposits of IgG and C3 at the dermoepidermal junction of both abnormal and clinically uninvolved skin, and in subepithelial deposits along the glomerular basement membrane.

Hereditary C2 Deficiency with Some Manifestations of Systemic Lupus Erythematosus

Summary A family with hereditary C2 deficiency was studied. The proposita, homozygous for this trait, showed certain clinical and serologic manifestations of systemic lupus erythematosus which included a widespread skin rash and a positive LE cell test.

Stevens-Johnson syndrome. Report of a case associated with culturally proven Mycoplasma pneumoniae infection.

THE CLINICAL manifestations of Stevens-Johnson syndrome (erythema multiforme exudativum) were frequently observed in the dermatology and dental services at the US Naval Hospital, Great Lakes, Ill, during the late summer and fall of 1965. The apparently increased incidence of this syndrome prompted clinical as well as laboratory investigations. The serological evidence of associated<i>Mycoplasma pneumoniae</i>infection in Stevens-Johnson syndrome presented by Ludlam et al¹suggested<i>Mycoplasma</i>studies. This communication is a case report of a patient with Stevens-Johnson syndrome in which an associated infection by<i>M pneumoniae</i>was documented by serological and cultural techniques. <h3>Report of a Case</h3> This 19-year-old white man was admitted to the US Naval Hospital, Great Lakes, on Oct 16, 1965, complaining of a widespread rash and sores in his mouth and on his penis. <h3>History.—</h3> He had been in a state of good health when he arrived at the Great Lakes Naval Station on

Stevens-Johnson Syndrome

THE CLINICAL manifestations of Stevens-Johnson syndrome (erythema multiforme exudativum) were frequently observed in the dermatology and dental services at the US Naval Hospital, Great Lakes, Ill, during the late summer and fall of 1965. The apparently increased incidence of this syndrome prompted clinical as well as laboratory investigations. The serological evidence of associated<i>Mycoplasma pneumoniae</i>infection in Stevens-Johnson syndrome presented by Ludlam et al¹suggested<i>Mycoplasma</i>studies. This communication is a case report of a patient with Stevens-Johnson syndrome in which an associated infection by<i>M pneumoniae</i>was documented by serological and cultural techniques. <h3>Report of a Case</h3> This 19-year-old white man was admitted to the US Naval Hospital, Great Lakes, on Oct 16, 1965, complaining of a widespread rash and sores in his mouth and on his penis. <h3>History.—</h3> He had been in a state of good health when he arrived at the Great Lakes Naval Station on

TRANQUILIZERS AND PURPURA HEMORRHAGICA

To the Editor:— Because of the widespread acceptance of the tranquilizing drug meprobamate, marketed under the names of Equanil and Miltown, I thought the following brief case report would be of interest. A 42-year-old female with insomnia, tension headaches, and other complaints of an anxiety nature was given meprobamate, 400 mg. three times a day, on March 15, 1956. After taking the third tablet she noted a feeling of warmth in the arms and thighs and on March 16 noted a widespread hemorrhagic rash on her axillas, breasts, chest, abdomen, arms, and inner thighs and legs. She continued the medication and had a temperature of 101 F (38.3 C), with hard, shaking chills and moderate edema of the legs and ankles. When seen on March 19, she had a widespread purpura involving the axillas, breasts, chest, arms, inner thighs and legs. Physical examination was otherwise not remarkable. No history was